Is Hong Kong Sanatorium & Hospital TESE Suitable for Azoospermia Patients? Indications & Complete Procedure Explained

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Starting from a Semen Report: How Doctors Determine if TESE is Right for You

In reproductive medicine clinics, when a patient's semen analysis report shows "no spermatozoa after centrifugation," the subsequent decision path is clear: first determine the type of azoospermia, then assess eligibility for surgical sperm retrieval. TESE (Testicular Sperm Extraction) performed at the Reproductive Medicine Centre of Hong Kong Sanatorium & Hospital offers azoospermia patients the opportunity to obtain their own sperm for ICSI, but this technique has clear indications. This article systematically reviews the suitable candidates, evaluation process, surgical details, and key considerations for TESE from a clinical decision-making perspective.

What Type of Azoospermia is TESE Suitable For?

The core value of TESE lies in directly searching for mature sperm within testicular tissue suitable for ICSI when sperm cannot be obtained through ejaculation or epididymal aspiration. Based on the etiological classification of azoospermia, the applicability of TESE is as follows:

Key Diagnostic Criteria: Patients with obstructive azoospermia typically have normal testicular volume (≥15 mL) and normal or mildly elevated FSH levels; patients with non-obstructive azoospermia often have reduced testicular volume (< 12 mL) and significantly elevated FSH levels (usually > 10 IU/L).

Etiological Classification of Azoospermia: Why Some are Suitable for TESE and Others are Not

Azoospermia accounts for approximately 10%~15% of male infertility cases, and the underlying cause directly determines the outcome of TESE. Understanding the etiological classification helps determine which category one belongs to.

Common Causes of Obstructive Azoospermia (OA)

• Epididymal Obstruction: Scarring following epididymitis or epididymal tuberculosis, preventing sperm passage through the epididymal duct.
• Vas Deferens Obstruction: Post-vasectomy, or accidental injury to the vas deferens during inguinal hernia surgery.
• Congenital Bilateral Absence of the Vas Deferens (CBAVD): Associated with CFTR gene mutations, often accompanied by seminal vesicle dysplasia.
• Ejaculatory Duct Obstruction: Cysts, strictures, or calcification of the ejaculatory duct causing blockage at the terminal end of the seminal tract.

Common Causes of Non-obstructive Azoospermia (NOA)

• Chromosomal Numerical Abnormalities: Klinefelter syndrome (47,XXY) is the most common cause, accounting for 10%~15% of NOA.
• Y-chromosome Microdeletions: Deletions in the AZFa, AZFb, or AZFc regions; patients with AZFc deletions still have a relatively high chance of sperm retrieval via TESE.
• History of Cryptorchidism: Bilateral undescended testes not surgically corrected in time, leading to irreversible damage to germ cells.
• Iatrogenic Injury: Chemotherapy, radiotherapy, or long-term use of gonadotoxic medications.
• Endocrine Factors: Idiopathic hypogonadotropic hypogonadism (IHH); such patients may induce spermatogenesis through hormone therapy and do not directly require TESE.
• Idiopathic Spermatogenic Failure: Unknown cause, accounting for 30%~40% of NOA cases.

How Doctors Evaluate TESE Indications: Three Core Dimensions

When determining if a patient is suitable for TESE, reproductive specialists systematically evaluate the following three dimensions:

Additionally, doctors will inquire about past history of cryptorchidism surgery, testicular torsion, mumps orchitis, chemotherapy, or radiotherapy, as this information is crucial for predicting the presence of residual spermatogenic foci within the testicles.

Characteristics of TESE at Hong Kong Sanatorium & Hospital

The Reproductive Medicine Centre at Hong Kong Sanatorium & Hospital has several noteworthy aspects in its application of TESE:

• Microdissection TESE (micro-TESE) as First Choice: For non-obstructive azoospermia, the hospital routinely uses microdissection testicular sperm extraction (micro-TESE) under an operating microscope. Compared to conventional TESE, this allows more precise localization of focal spermatogenic foci, reduces testicular tissue damage, and improves sperm retrieval rates.
• Intraoperative Frozen Section Pathology: Testicular tissue removed during surgery is immediately sent for frozen section examination to confirm the presence of mature sperm, avoiding ineffective procedures.
• ICSI Laboratory Conditions: Retrieved sperm are used directly for ICSI. The hospital's embryology laboratory is equipped with time-lapse imaging incubators, laser-assisted hatching, and other devices to support continuous monitoring of embryos after single sperm injection.
• Multidisciplinary Collaboration Model: The reproductive medicine department, urology department, pathology department, and genetic counseling team work together, completing genetic counseling and risk assessment before surgery.

Key differences between hospitals in TESE technology include: routine use of micro-TESE, availability of intraoperative frozen pathology, laboratory experience with ICSI, and postoperative complication management protocols. As a long-established private hospital in Hong Kong, Sanatorium & Hospital has mature standardized procedures for all the above aspects.

Easily Overlooked Details: Preoperative Tests and Preparation

In clinical practice, patients most often overlook the following key steps:

• Y-chromosome Microdeletion Testing is Essential: Some patients believe that having a karyotype analysis makes Y-chromosome microdeletion testing unnecessary, but these two tests cover different genetic information. Y-chromosome microdeletion testing can determine if the AZF region is deleted, directly influencing whether TESE is worth attempting.
• CFTR Gene Testing (for CBAVD): If semen volume is low (< 1.5 mL), pH is acidic, and seminal plasma fructose is negative, it may indicate congenital bilateral absence of the vas deferens, requiring CFTR gene testing. Both the patient and his partner need testing to assess the genetic risk for offspring.
• At Least Two Preoperative Semen Centrifugation Tests: A single semen report showing "no sperm" is not sufficient for diagnosis. It should be repeated after an interval of 2~4 weeks, and diagnosis must be based on the examination of the centrifuged sediment.
• Timing of Hormone Tests: FSH, LH, and Testosterone should be measured via fasting blood draw between 8:00 and 10:00 AM, as testosterone levels have a circadian rhythm; afternoon results may be lower, affecting clinical judgment.
• Details of Testicular Ultrasound: Besides measuring volume, attention should be paid to the presence of testicular microlithiasis, calcifications, or space-occupying lesions, as these findings may influence the surgical strategy.

Actual TESE Procedure: From Preoperative Preparation to Postoperative Recovery

The TESE procedure at Hong Kong Sanatorium & Hospital typically follows these steps:

Phase 1: Preoperative Preparation (Approximately 2~4 weeks)

• Complete hormone panel (FSH, LH, Testosterone, PRL, E2, AMH)
• Complete chromosome karyotype analysis + Y-chromosome microdeletion testing
• Complete scrotal ultrasound (testicular volume, epididymis, vas deferens, seminal vesicles)
• Genetic counseling (if genetic abnormalities are found)
• Infection screening (Hepatitis B, Hepatitis C, Syphilis, HIV, etc.)
• Sign surgical informed consent (with emphasis on the risk of failed sperm retrieval)

Phase 2: Day of Surgery (Typically outpatient surgery, 1-night stay)

• Anesthesia Method: Local anesthesia with sedation, or general anesthesia (chosen based on patient condition and doctor's recommendation).
• Surgical Steps: Midline scrotal incision → exposure of testis → incision of tunica albuginea → search for dilated seminiferous tubules under an operating microscope (micro-TESE) → removal of a small amount of testicular tissue (approximately 50~200 mg) → sent for frozen section pathology → after confirming the presence of sperm, place remaining tissue in specialized culture medium → suture tunica albuginea and incision.
• Simultaneous Oocyte Retrieval: TESE is usually scheduled on the same day as the female partner's egg retrieval to ensure retrieved sperm can be used directly for ICSI, avoiding freeze-thaw damage.

Phase 3: Postoperative Recovery (Approximately 1~2 weeks)

• Mild scrotal swelling and pain post-surgery are normal; ice packs can be used to alleviate symptoms.
• Rest is recommended for 3~5 days, avoiding strenuous exercise, prolonged standing, or cycling.
• Avoid sexual activity for 1 week post-surgery.
• If significant scrotal enlargement, fever, wound bleeding, or pus discharge occurs, return to the clinic promptly.
• 1 month post-surgery, a scrotal ultrasound is performed to assess hematoma absorption and wound healing status.

Interpreting Key Test Results: Understanding Your Lab Report

Below are the most critical test indicators for evaluating TESE candidacy in azoospermia patients, along with their clinical interpretation:

Typical Scenario Analysis: When TESE is Suitable and When It Is Not

Scenario 1: Post-vasectomy
32-year-old male, 5 years post-vasectomy, semen analysis shows azoospermia, FSH 5.2 IU/L, testicular volume 18 mL. TESE sperm retrieval success rate > 95%, making it an ideal indication. Options include TESE or epididymal aspiration (PESA), with similar success rates.

Scenario 2: Klinefelter Syndrome
28-year-old male, karyotype 47,XXY, FSH 22 IU/L, testicular volume 4 mL. Micro-TESE sperm retrieval success rate is approximately 45%~55%. Preoperative counseling regarding the possibility of failed retrieval is essential, and concurrent testicular tissue cryopreservation should be considered.

Scenario 3: Complete AZFa Region Deletion
35-year-old male, FSH 18 IU/L, testicular volume 8 mL, Y-chromosome microdeletion report shows complete AZFa deletion. The reported TESE success rate in the literature is extremely low (< 5%); surgery is generally not recommended, and donor sperm or adoption should be considered directly.

Scenario 4: Idiopathic Hypogonadotropic Hypogonadism (IHH)
24-year-old male, FSH 0.8 IU/L, LH 0.6 IU/L, Testosterone 3.5 nmol/L, testicular volume 6 mL. Such patients do not directly require TESE. Instead, they should first receive gonadotropin therapy (hCG + FSH) for 6~12 months; some may recover spermatogenesis and achieve sperm in their ejaculate.

Frequently Asked Questions Summary

• Q: Does TESE surgery affect testosterone levels?
  A: Unilateral TESE has a minimal impact on overall testosterone levels. However, bilateral procedures or removal of a large amount of testicular tissue may lead to a decrease in testosterone. Postoperative monitoring of sex hormones is necessary, and androgen supplementation may be required.
• Q: Can sperm retrieved via TESE be used directly for IVF?
  A: Yes. Sperm retrieved via TESE is typically used for ICSI (Intracytoplasmic Sperm Injection) and cannot be used for conventional IVF because testicular sperm have low motility and require manual selection of morphologically normal sperm for direct injection into the egg.
• Q: Can one TESE procedure retrieve enough sperm?
  A: For obstructive azoospermia, one procedure usually retrieves enough sperm for ICSI, and excess sperm can be cryopreserved. For non-obstructive azoospermia, sometimes only a few sperm are found, which may be sufficient for only one ICSI cycle.
• Q: Is hospitalization required for TESE?
  A: At Hong Kong Sanatorium & Hospital, TESE is typically performed as an outpatient procedure or requires a 1-night stay. Patients can be discharged after observation if no complications arise.
• Q: How much does TESE surgery cost?
  A: The cost of TESE varies depending on the hospital, anesthesia method, whether micro-TESE and intraoperative frozen pathology are performed. At Hong Kong Sanatorium & Hospital, the cost typically ranges from HKD 30,000 to 60,000 (excluding ICSI and embryo culture fees). Please consult the hospital for specific pricing.
• Q: Are there alternatives if TESE fails?
  A: If TESE fails to find sperm, options include donor sperm insemination or donor sperm IVF, or considering adoption. Some patients may also opt for testicular tissue cryopreservation, awaiting future technological breakthroughs.

Risk Reminder

This article is based on general knowledge in the assisted reproduction field and is intended for medical knowledge reference only. It does not constitute medical advice. Specific surgical indications and plans should be evaluated and determined by a reproductive medicine specialist based on the patient's individual circumstances.